*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Abortion

X

Expenses for operations that are not legal do not
qualify.

Acupuncture

X

Adaptive Equipment

X

Adaptive equipment for a major disability, such as a
spinal cord injury, can be reimbursed.

Adaptive equipment to assist you with activities of daily living can be
reimbursed.

Eligible expenses include products and home improvements to treat severe
allergies. Examples include:

Electro-static air purifier

Humidifier

Home air conditioners

Pillows, mattresses covers, etc to alleviate an allergic condition.
If used to treat or alleviate a specific medical condition, only the
excess cost of the specialized products over the cost of a regular/like
item will qualify.

Nontraditional healing treatments provided by professionals may be
eligible if provided to treat a specific medical condition. The
treatments must be legal. And the expenses do not qualify if the remedy
is a food or substitute for food that the person would normally consume
in order to meet nutritional requirements. Drugs and medicines
recommended by alternative healers to treat a specific medical condition
also can qualify as medical care, although drugs and medicines incurred
after December 31, 2010 must be prescribed by an individual legally
authorized to issue prescriptions in the applicable state in order to
qualify.

Alternative Medicine

X

Services must be prescribed and rendered by a licensed health care
provider to treat a specific illness or disorder.

Will qualify to the extent that procedures are intended to overcome an
inability to have children due to medical reasons and are performed on
you, your spouse or your dependent. Eligible medical expenses
include (but are not limited to):

Fertility exams

Artificial insemination (intracervical, intrauterine, intravaginal)

In-vitro/In-vivo fertilization

Gamete Intrafallopian Transfer (GIFT)

Sperm bank storage/fees for artificial insemination.
*Note: Storage fees can only be submitted for planned fertilizations
during the current plan year.

Sperm implants

Sperm washing

Reverse vasectomy

- Embryo replacement and storage.
*Note: Storage fees can only be submitted for planned fertilizations
during the current plan year.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Baby Formula

X

If your baby requires a special formula to treat an
illness or a disorder, the difference in cost between the special
formula and routine baby formula can be reimbursed.

Band-Aids/Bandages

X

Bedboards

X

Bedside Commodes

X

Bed Wetting Alarm

X

Covered for children 5 years of age or older.

Before and After School Care

X

Child must be under age 13 or one who is incapable of
self-care.

Birth Control

X

Blood Pressure Monitors

X

Blood Storage

X

Blood storage is an eligible expense if you are
storing blood for use during scheduled elective surgery. Storage
fees should not exceed six months.

Body Scans

X

Boutique Practice Fees

X

Monthly or annual fees that your provider may charge
for improved access and more personalized care are not considered
medical care and cannot be reimbursed.

Braille Books and Magazines

X

The incremental cost of Braille books and magazines
that exceeds the price for regular books and magazines is an eligible
expense.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Camps (summer or holiday day camps)

X

This includes daycare as well as in-home babysitters
for children under age 13, or any individual who is incapable of
self-care.

Payment in advance is not covered. You can only be reimbursed for
expenses that have been incurred.

Camps (soccer, football, ballet, etc. day camps)

X

These are not eligible. However, if
the primary purpose of these camps is for care and well-being in order
for you (or you and your spouse if you are married) to be gainfully
employed, these expenses may qualify. If ASIFlex cannot
independently verify the primary purpose of the camp, ASIFlex will
request a statement from the participant that verifies the primary
purpose is the care and well-being of the child, and not for
educational/instructional purposes.

Camps (overnight)

X

Overnight camps are not an eligible expense.

Capital Expense

X

A capital expense (permanent or portable) can be
reimbursed if its purpose is to provide medical care for you, your
spouse or dependent.

Expenses for improvements or special equipment added to your home can be
reimbursed if the main purpose of the item is medical care. How much is
reimbursed depends on the extent to which the expense permanently
improves the property and whether others benefit.

The amount paid for the improvement is reduced by the increase in the
value of your home or property. The difference between the cost of the
improvement minus the increased value equals the eligible expense.

If the value of your home or property is not increased by the
improvement, the entire cost is an eligible expense. Use the
Capital
Expense Worksheet to determine if your expense is eligible.

Childbirth Classes

X

Expenses are eligible for the woman who is having the
child. Expenses for the spouse or partner attending the class with
the pregnant woman are not eligible.

Chiropractic Care

X

Christian Science Practitioners

X

Cialis

X

Circumcision

X

A bris performed in the home by a Rabbi is not an
eligible expense.

COBRA Premiums

X

Co-Insurance

X

Companion Animals

X

Expenses to train or procure any guide dog, signal dog,
or other animal individually trained to provide assistance to you, your
spouse or dependent with a disability can be reimbursed under a Health Care Flexible Spending Account.

Compression hose/socks
(includes diabetic socks)

X

Concierge Medical Care

X

The cost of joining such a program is not
reimbursable such as monthly or annual fees. However, actual care (i.e.,
physical exam, office visit, etc.) provided by physicians belonging to
such programs would be covered when billed after such care is provided
-- so long as it is not unreasonably expensive and so long as it has not
and will not be reimbursed from other health plan coverage.

Contact Lenses

X

Co-Payments

X

Cord Blood Storage

X

Can be reimbursed if there is a specific medical
condition that the cord blood is intended to treat. Indefinite
storage "just in case" is not an eligible expense.

Corneal Ring Segments

X

Cosmetic Procedures or Drugs

X

Cosmetic procedures to improve or enhance appearance
are not eligible.

A cosmetic procedure, service or prescription drug necessary to improve
a deformity arising from a congenital abnormality, personal injury from
accident or trauma, or to restore proper function of the body related to
treatment for another medical diagnosis or condition can be reimbursed.

Counseling

X

If counseling is provided to treat a medical or
mental diagnosis and is rendered by a licensed provider, the expense is
eligible.
Life coaching, career counseling and marriage counseling do not qualify.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Daycare

X

Daycare is an eligible expense under the Dependent
Care Flexible Spending Account only, not
the Health Care Flexible Spending Account. This includes daycare as well as in-home
babysitters for children under age 13, or any individual who is
incapable of self-care. If you are part of a divorced household, you
must be the custodial parent for more than 50% of the year.

Payment in advance is not covered. You can only be reimbursed for
expenses that have been incurred.

Dancing Lessons

X

Only for a short duration and if prescribed for a
specific medical condition, such as a rehabilitation program after
surgery.

Won't qualify if used for personal or preventive reasons. If used to
treat or alleviate a specific medical condition, only the excess cost of
the specialized shoes over the cost of regular shoes will qualify.

To show that the expense is
primarily for medical care, a note from a medical practitioner
recommending the item to treat a specific medical condition is normally
required.

Diabetic Supplies

X

Diaper Rash Creams

X

Diapers

X

Doulas

X

If the doula is a licensed health care professional
who renders medical care, his or her fees can be reimbursed.

Drug Addiction

X

Eligible expenses include inpatient treatment,
outpatient care and transportation expenses associated with attending
outpatient treatment.
If court-ordered treatment, a letter of medical necessity will be
required.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Ear Plugs

X

Must be prescribed to treat a specific medical
condition such as the presence of middle/inner ear tubes.

Education

X

Payments made to a special school for a mentally
impaired or physically disabled person qualify as reimbursable if the
main reason for using the school is its resources for relieving the
disability. This includes teaching Braille to a visually impaired
person, teaching lip reading to a hearing impaired person, and giving
remedial language training to correct a condition caused by a birth
defect.

Education - Dependent Care

X

Expenses for a child in nursery school, pre-school, or
similar programs for children below the level of kindergarten are
expenses for care.

Expenses to attend kindergarten or a higher grade are not expenses for
care. Summer School and tutoring programs are not for care.

Elder Care

X

Adult must live with you at least 8 hours a day and
be claimed as a dependent on your Federal Tax return.

Electrolysis

X

Ergonomic Items

X

Requires a letter of medical necessity, and only the
difference in cost between the purchased item(s) and a similar
non-specialty item.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Condition/Type of Service

Eligible

Potentially Eligible

Not Eligible

Additional Information

Face Wash, medicated

X

Covered with a letter of medical necessity for
medical conditions such as acne, rosacea, etc. Also covered if the
primary use of the product is for the treatment of acne.

Face Wash, non medicated

X

The cost of regular skin care is not covered.

Fertility Enhancement

X

Includes ovulation predictor kits and pregnancy
tests.

Fertility Treatments

X

Will qualify to the extent that procedures are
intended to overcome an inability to have children due to medical
reasons and are performed on you, your spouse or your dependent.

Finance Charges

X

First Aid Kit

X

The first aid kit must be reasonably priced.

NOTE: The method of achieving the intended medical
result cannot be unreasonably expensive or lavish. The excessive-cost
concerns are most prevalent in the cases involving personal purposes.
Thus, if there is a less expensive way that the recommended treatment
can be obtained, the excess expense might not be reimbursable. There is
no requirement, however, that an employee choose the least-expensive
alternative for treating a disease.

Fitness Programs

X

Fees paid for a fitness program may be an eligible
expense if prescribed by a physician and substantiated by his or her
statement that treatment is necessary to alleviate a medical condition.
Additionally, the affected individual must include a statement with
his/her claim stating that "but for the medical condition" he or she
would not have joined the fitness program.

Flu Shots

X

Food

X

Food is not normally an eligible expense unless the
food is prescribed by a medical practitioner to treat a specific illness
and does not substitute for normal nutritional requirements.

Funeral Expenses

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. The letter will remain on file one year from the date
written.

Will qualify if used primarily for medical care (for example, to treat
arthritis). Won't qualify if used just to maintain general health. To
show that the expense is primarily for medical care, a note from a
medical practitioner recommending the item to treat a specific medical
condition (for example, arthritis) is normally required.

Guide Dogs

X

Gift Cards

X

Gift cards are not an eligible expense, even if these
cards are provided by a medical provider such as an eye glass store or
pharmacy.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter
will remain on file one year from the date written.

Requires a Letter of Medical Necessity and a
statement from the individual stating "but for" the medical condition
listed in the letter of medical necessity, he or she would not have
joined the health club/gym.

You cannot be reimbursed for expenses that will be incurred in the
future, even if payment is required in advance. In addition, the fees no
longer qualify when treatment is no longer needed.

Hearing Aids

X

Hearing Aids and related expenses (such as fittings, exams to put them in place and batteries) are all eligible for reimbursement through the Flexible Spending Account.

Health Screenings

X

Holistic or Natural Healers, Dietary Substitutes,
and Drugs and Medicines

X

Home Medical Equipment

X

Homeopathic Care

X

Homeopathic care rendered by a licensed health care
professional who provides this care for the treatment of a specific
illness or disorder for you, your spouse or dependent can be reimbursed
under a Health Care Flexible Spending Account.

Humidifiers

X

Requires a Letter of Medical Necessity if deteremined
to be a Captial Expense. See Capital Expenses for more
information.

Hydrotherapy

X

Hypnosis

X

Could qualify if performed by a professional to treat a medical condition, or for other medical purposes (e.g., smoking cessation); won’t qualify if for general stress relief, personal enjoyment, or other personal purposes. A note from a medical practitioner recommending it to treat a specific medical condition is required.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. This letter must be submitted with every claim.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. This letter must be submitted with every claim.

If a woman is having lactation problems and cannot
breastfeed her child, then the expense of a lactation consultant helping
to overcome this dysfunction might qualify. To show that the expense is
primarily for medical care, a note from a medical practitioner
recommending it to treat a specific medical condition is required.

Lamaze Classes

X

Expenses are eligible for the woman who is having the
child. Expenses for the spouse or partner attending the class with the
pregnant woman ARE NOT ELIGIBLE.

Laser Eye Surgery

X

Lead Based Paint Removal

X

Expenses for removing lead-based paints from surfaces
in your home to prevent a child who has or has had lead poisoning from eating the paint can be reimbursed. These surfaces
must be in poor repair and within a child’s reach.

The cost of repainting the affected area(s) is not an eligible expense.
If you cover the area with wallboard or paneling instead of removing the
lead paint, these items will be treated as capital expenses.

Learning Disabilities

X

The portion of tuition/tutoring fees covering services
rendered specifically for your child's severe learning disabilities
caused by mental or physical impairments (such as nervous system
disorders, or closed head injuries) and paid to a special school or to a
specially-trained teacher may be reimbursed under a Health Care Flexible Spending Account if prescribed
by a physician. Examples of eligible expenses include:

Fees or advance payments made to a retirement home or
continuing care facility are not eligible expenses.

Lodging

X

Up to $50 per night is eligible if the following
conditions are met:

The lodging is primarily for, and essential to, medical care

The medical care is provided by a doctor in a licensed hospital or
medical care facility related to/equivalent to a licensed hospital

The lodging is not lavish or extravagant

There is no significant element of personal pleasure or leisure in the
travel.

Your companion’s lodging can be reimbursed if he or she is accompanying
the patient (you or your eligible dependents) for medical reasons and it
meets the criteria listed above. Meals are not eligible for
reimbursement.

Example: Parents traveling with a sick child, up to $100 per night ($50
per person) may be reimbursed, as well as lodging and pre and
post-hospitalization for bone marrow transplants.

Long-Term Care Insurance Premiums

X

Long-Term Care Services

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the
diagnosis for which you, your spouse or dependent
are being treated, along with specific information on how the
product or service is intended to alleviate symptoms or improve
function. This letter must be submitted with every claim.

Therapeutic Massage treating a specific medical
condition can be reimbursed under a Health Care Flexible Spending Account. The words “therapy” or
“therapeutic” must be included in the description of the service and a
letter of medical necessity must be provided. Gratuities are not
reimbursable.

Maternity Clothes

X

Medical Alert Bracelet

X

Medical Records

X

Amounts paid to a plan that maintains electronic
medical information for you, your spouse or dependents are eligible for
reimbursement under an Health Care Flexible Spending Account.Costs associated with copying or transferring
medical records to a new provider are eligible for reimbursement.

Mileage Expenses

X

Effective January 1, 2015, reimbursement for
mileage for medical care has been reduced by ½ cent to 23 cents per
mile.

To submit a claim for mileage expenses, please list the number of miles,
the date of service and the dollar amount of the mileage expense you are
claiming. The provider information should also be listed on the claim
form.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

Naturopathic care rendered by a licensed health care
professional who provides this care for the treatment of a specific
illness or disorder for you, your spouse or dependent can be reimbursed
under a Health Care Flexible Spending Account.

Non-Covered Services

X

Medical care or services that are not covered under
your major medical plan may be reimbursed under an Health Care Flexible Spending Account.

Newborn Nursing Care

X

Nursing services for a normal, healthy newborn are not
an eligible expense.

Nursing Care and Services (private duty nursing)

X

Nursing services are an eligible expense, whether
provided in your home or another facility. The nurse need not be an R.N.
or L.P.N., so long as the services rendered are of a kind generally
performed by a nurse. These include services directly related to caring
for and monitoring your, your spouse’s or dependent’s condition,
including:

Preparing and giving medication

Changing dressings and providing wound care

Monitoring vital signs

Assessing responses to prescribed treatments, and documenting those
assessments in written notes

If the individual providing nursing services also provides household and
personal services, only those charges related to actual nursing care are
eligible expenses.

Nursing Home

X

Expenses for medical care in a nursing home for you,
your spouse and dependent(s), including meals and lodging may be
reimbursed if the main purpose of the stay is to receive medical care.

If the primary reason for confinement is personal (i.e., you or your
spouse or dependent needs assistance with activities of daily living,
safety issues, etc.), only the portion of the cost that is directly
related to medical care or nursing services may be reimbursed.

Nutritional Supplements

X

Dietary, nutritional, and herbal supplements, vitamins,
and natural medicines are not reimbursable if they are merely beneficial
for general health. However, they may be reimbursable if recommended by
a medical practitioner to treat a specific medical condition.

Nutritionist

X

Nutritional services related to the treatment and
guidance of a specific diagnosis or medical condition can be reimbursed.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

Both custom-made and over-the-counter inserts are
eligible for reimbursement.

Orthopedic Shoes

X

Won't qualify if used for personal or preventive
reasons. If used to treat or alleviate a specific medical condition,
only the excess cost of the specialized orthopedic shoe over the cost of
a regular shoe will qualify.*
To show that the expense is primarily for medical care, a note from a
medical practitioner recommending the item to treat a specific medical
condition is normally required.

A proper receipt must contain all of the following information: 1) name
of the item or service; 2) the date of purchase or service; and 3) the
amount paid. Note for over-the-counter items: If the receipt does not
include this information, copy the label from the product or its
packaging, circle the correct amount on the receipt, and submit this
information with the signed claim form.

Over-the-Counter Items and Supplies that are Dual
Purpose

X

Dual purpose items (a product used to alleviate medical
conditions but also used for general health) may be eligible but require
a letter of medical necessity, only the
difference in cost between the purchased item(s) and a similar
non-specialty item and a proper receipt.

A proper receipt must contain all of the following information: 1) name
of the item or service; 2) the date of purchase or service; and 3) the
amount paid. Note for over-the-counter items: If the receipt does not
include this information, copy the label from the product or its
packaging, circle the correct amount on the receipt, and submit this
information with the signed claim form.

Ovulation Monitor

X

Oxygen

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

While these exercises are often done by family members,
the expense to hire someone to perform patterning exercises is an
eligible expense.

Penile Implants

X

Amounts paid for implants may be eligible if the
diagnosis of impotence is due to organic causes, such as diabetes,
post-prostatectomy complications, or spinal cord injury.

Physical Therapy

X

Placement Services

X

The up-front fee may qualify if it is an expense that
must be paid in order to obtain care. However, the fee can only be
reimbursed proportionately over the duration of the agreement to employ
the dependent care provider, such as an au pair. The weekly stipend, as
well as other work-related expenses, may also qualify as an expense for
the care of a qualifying individual.

Pregnancy Aids

X

Items that relieve or reduce the discomfort of
pregnancy may be reimbursed under a Health CareFlexible Spending Account. Examples include:

Maternity girdles

Elastic hosiery

Maternity support belts - does not include bands used to assist with
fitting into pre-pregnancy clothing

Pregnancy Tests

X

Pre-School - Dependent Care

X

Expenses for a child in nursery school, pre-school, or
similar programs for children below the level of kindergarten are
expenses for care.

Expenses to attend kindergarten or a higher grade are not expenses for
care. Summer School and tutoring programs are not for care.

Prescription Drug Discount Program

X

Fees paid to get access to drugs at a reduced cost are
not eligible for reimbursement under a Health Care Flexible Spending Account. Actual costs paid for
prescription drugs are an eligible expense.

Prescription Drugs

X

Eligible expenses include deductibles, co-payments or
co-insurance as well as the costs for prescription drugs that may not be
covered under your major medical plan, such as drugs that treat erectile dysfunction.

HOWEVER, prescription drugs taken solely for cosmetic
purposes do not qualify.

Prescription Drugs - IMPORTED

X

IRS regulations state that any drug imported into the
United States by a consumer is not eligible for reimbursement under a
Flexible Spending Account.

Preventive Care Screenings

X

If the tests are designed to assess symptoms of a
medical diagnosis, they are eligible for reimbursement. Examples include
clinic and home testing kits for blood pressure, glaucoma, cataracts,
hearing, cholesterol, etc.

Propecia

X

Hair growth treatments are considered to be cosmetic
and are not eligible for reimbursement.

Prosthetics

X

Psychiatric Services and Care

X

Psychoanalysis

X

Psychologist

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

If a physician requires radon mitigation in your home
due to a medical condition caused or aggravated by an unacceptable level
of radon, some expenses may be eligible. However, if the home’s value is
increased due to the mitigation, some or all of the expenses may not be
reimbursable. Use the Capital Expense Worksheet to determine how much of
the expense is eligible.

Reading Glasses

X

Reflexology

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

Expenses to train or procure any guide dog, signal dog,
or other animal individually trained to provide assistance to you, your
spouse or dependent with a disability can be reimbursed under a Health Care Flexible Spending Account.

Shipping and Handling

X

Shipping and handling charges for medical needs, such
as mail-order prescriptions.

Smoking Cessation Programs

X

Smoking Cessation Products

X

Products such as nicotine gum and patches will require
a prescription from a medical doctor before being eligible.

Sonicare Toothbrushes
*See Toothbrushes

X

Toothbrushes will not qualify even if a dentist
recommends special ones (such as electronic or battery-powered ones) to
treat a medical condition like gingivitis. Toothbrushes are items that
are used primarily to maintain general health - a person would
still use one even without the medical condition. Thus, they are not
primarily for medical care.

Speech Therapy

X

Sperm/Egg Storage

X

Fees for temporary storage might qualify, but only to
the extent necessary for immediate conception. Storage fees for
undefinded future conception probably aren't considered to be for
medical care.

NOTE: Storage fees can only be submitted for planned
usage during the current plan year.

Sterilization Procedures

X

Sterilization Reversal

X

Student Health Fee

X

Substance Abuse Treatment

X

Sunburn creams and ointments, medicated

X

Will qualify if used to treat a sunburn (and not as regular skin
moisturizers), but must be prescribed if incurred after December 31,
2010.

Sun-Protective Clothing

X

Won’t qualify if used to maintain general health or for
other personal reasons. May qualify if used to treat or alleviate a
specific medical condition (e.g., melanoma) and if the expense would not
have been incurred “but for” the condition, but only the excess cost of
the specialized garment over the cost of ordinary clothing will qualify.
To show that the expense is primarily for medical care, a note from a
medical practitioner recommending the item to treat a specific medical
condition is normally required.

Sunscreen

X

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

Taxes on medical services and products may be
reimbursed under a Health Care Flexible Spending Account. This includes local, state, service and other
taxes.

Teeth Whitening

X

Teeth whitening products or services to enhance the
brightness of your teeth are cosmetic and cannot be reimbursed.

Telephone for Hearing Impaired

X

Expenses associated with purchasing or repairing
special telephone equipment for you, your spouse or dependent with a
hearing impairment are eligible for reimbursement under a Health Care Flexible Spending Account.

Television

X

Expenses for equipment that displays the audio of
television programming as subtitles for hearing impaired persons are
eligible for reimbursement under a Health Care Flexible Spending Account.

The eligible expense is limited to the cost that exceeds the cost of a
non-adapted set.

Toothbrush

X

Won't qualify even if a dentist recommends special ones (such as
electric or battery-powered) to treat a medical condition like
gingivitis. Toothbrushes are items that are used primarily to maintain
general health—a person would still use one even without the medical
condition. Thus, they are not primarily for medical care.

Toothpaste

X

Won't qualify even if a dentist recommends a special one to treat a
medical condition like gingivitis. Toothpaste is an item that is
primarily used to maintain general health—a person would still use it
even without the medical condition. Thus, it is not primarily for
medical care.† But topical creams or other
drugs (e.g., fluoride treatment) used to treat a dental condition would
qualify, so long as they are primarily for medical care.

Transportation

X

Car mileage, bus, taxi, and subway or train fare for
travel to and from receiving medical care, including health care
providers, hospitals and pharmacies can be reimbursed.

Mileage incurred traveling to and from your medical provider is
reimbursable through the Health Care Flexible Spending Account.

To ensure your transportation claim is approved, be sure to submit your
receipt(s) or an itemization of your travel with the claim that
coincides with the service(s) rendered.

In some cases, transportation expenses of the following persons may be
reimbursed:

A parent who must go with a child who needs medical care

A nurse or other person who can give injections, medications or other
treatment required by a patient traveling to get medical care and who is
unable to travel alone

Visits to see your mentally ill dependent, if part of a treatment plan

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.

Medical expenses in excess of your plan’s usual,
customary and reasonable (UCR) charges may be reimbursed under a Health Care Flexible Spending Account
if the underlying expense is eligible.

Ultrasound, Pre-Natal

X

An ultrasound ordered by your physician to monitor
fetal growth, and/or to diagnose, treat or monitor a pregnancy-related
condition is a covered expense under your Health Care Flexible Spending Account, even if your health
plan does not provide reimbursement. An ultrasound not ordered or
performed by a physician or other licensed professional, and/or not
intended to diagnose, treat or monitor a pregnancy-related condition is
not an eligible expense.

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. TThe letter will
remain on file one year from the date written.

Fees paid to gain access to a vision network, or to a
reduced fee structure are not an eligible expense under a
Health Care Flexible Spending Account.

Vitamins

X

See OTC

*Please note,
all "potentially eligible expenses" require a
letter
of medical necessity
from your health care provider in order to be considered
eligible for reimbursement. The letter must include the diagnosis for which you, your spouse or dependent are being treated,
along with specific information on how the product or service is
intended to alleviate symptoms or improve function. The letter will
remain on file one year from the date written.